Claims:

2. The composition of claim 1 wherein the composition is also useful in
treating inflammation and bacterial infections in the eye following
ophthalmic surgical procedures.

3. The composition of claim 1 wherein the concentration of gatifloxacin
is 0.01% to 1.5% w/v.

4. The composition of claim 1 wherein the concentration of prednisolone
is 0.01% w/v-2.0% w/v.

5. The composition of claim 3 wherein the concentration of gatifloxacin
is 0.1% w/v-0.5% w/v.

6. The composition of claim 4 wherein the concentration of prednisolone
is 0.1% w/v-1.5% w/v.

7. The composition of claim 5 wherein the concentration of gatifloxacin
is 0.3% w/v.

8. The composition of claim 6 wherein the concentration of prednisolone
is 1.0% w/v.

9. The composition of claim 1 wherein the concentration of gatifloxacin
is 0.3% w/v and the concentration of prednisolone is 1.0% w/v.

10. The composition of claim 9 further comprising benzalkonium chloride.

11. The composition of claim 10 wherein the benzalkonium chloride is
present in the amount of 0.005% w/v.

12. The composition of claim 11 wherein the pH is in the range of 6.5 to
7.4.

13. The composition of claim 12 wherein the composition has an osmotic
value from 250 to 350 milliosmoles per kilogram of water.

14. The use of the composition of claim 13 in the manufacture of a
medicament for treatment of bacterial conjunctivitis and inflammatory
conditions following eye surgery by applying said composition to each 1
to 4 times eye per day.

Description:

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application is a Continuation of U.S. patent application Ser.
No. 13/938,825 filed on Jul. 10, 2013, which is a Continuation of U.S.
patent application Ser. No. 13/205,785 filed on Aug. 9, 2011, which is a
Continuation of U.S. patent application Ser. No. 12/554,514 filed on Sep.
4, 2009, which claims priority to U.S. Provisional Patent Application No.
61/095,452, filed on Sep. 9, 2008, which are incorporated by reference
herein in their entirety.

[0003] Quinolone antibiotics are frequently used to prevent and treat
ophthalmic infections and in general represents the current state of the
art in the field of ophthalmic pharmaceutical compositions and methods of
treatment. Some quinolone antibiotic compositions are effective in
treating ophthalmic infections and have distinct advantages over prior
ophthalmic antibiotic compositions, particularly those having relatively
limited spectrums of antimicrobial activity. For example, neomycin,
polymyxin B, gentamicin and tobramycin are primarily useful only against
gram negative bacteria while bacitracin, gramicidin, and erythromycin are
primarily useful only against gram positive bacteria. Thus quinolone
antibiotics have advantages over many other classes of antibiotics in
that they are broad spectrum. However, despite the general efficacy of
available ophthalmic antibacterial compositions, there exists a strong
need for improved quinolone ophthalmic antibacterial composition and
methods of treatments of ophthalmic infections, particularly those
associated with inflammatory conditions, which are more effective than
existing ophthalmic antibacterial compositions in treating key ophthalmic
bacteria and which are less prone to the development of resistance by
those bacteria. There is also a need for an ophthalmic composition which
is useful in treating or preventing bacterial infection and inflammation
both before and after eye surgery.

[0004] Thus it is an object of the invention to provide a topical
ophthalmic preparation consisting of a fourth generation quinolone as
anti-infective agent and an anti-inflammatory agent;

[0005] It is a further object of the invention to provide an ophthalmic
composition comprising an anti-infective agent and an anti-inflammatory
agent in pharmaceutically acceptable excipients and vehicle with an
acceptable pH and viscosity;

[0006] It is a further object of the invention to provide a clear, stable
aqueous suspension composition of an anti-infective and a steroidal
anti-inflammatory which when administered topically to the eye, does not
cause any irritation/discomfort to the eye; and,

[0007] It is a further object to provide aforesaid ophthalmic composition
having more patient compliance and acceptability.

SUMMARY OF INVENTION

[0008] The present invention is directed to a unique and efficacious
combination of gatifloxacin and prednisolone for the treatment of
ophthalmic bacterial infections and for the prevention of inflammation.
The gatifloxacin and prednisolone compositions of the present invention
are useful in both the treatment and prophylaxis of patients undergoing
ophthalmic surgical procedures and may be used pre- or post-operatively
to prevent or treat both inflammation and bacterial infection.

[0009] Ophthalmic infections are frequently accompanied by inflammation of
the infected ophthalmic tissues and sometimes the surrounding tissues.
Similarly, ophthalmic surgical procedures that pose a risk of microbial
infections may also cause inflammation of the affected tissues. Thus,
there is a need for ophthalmic pharmaceutical compositions which combine
the anti-infective activity of one or more broad spectrum antibiotics
with the anti-inflammatory properties of one or more steroidal or
non-steroidal agents in a single composition.

[0010] Inflammatory disease is the third most frequent eye perturbation
(after refraction error and dry eye syndrome) and topical corticosteroids
for treatment of inflammatory conditions are well accepted among
practitioners. Inflammatory conditions caused by invasive surgical
procedures to the eye must also be considered, such as those caused by
ophthalmic surgeries, in which the presence of infection in the post-op
period is a constant concern by ophthalmologists. There is also the
concern of inflammatory conditions which may exist pre-operatively which
may be associated with a bacterial infection which will worsen
post-operatively. When these infections are caused by virulent bacteria,
it is possible that these bacterial infections can spread to other eye
tissues/structures leading to sight threatening conditions.

[0011] Most cases of bacterial conjunctivitis are caused by Streptococcus
pneumoniae, Haemophilus influenzae and Streptococcus sp. The prophylactic
use of antibiotics both before and after invasive surgical procedures of
the eye is an accepted therapeutic treatment and widely used in
ophthalmology, as is documented in the literature. The constant search
for new and more powerful broad spectrum antibiotic treatments has been
encouraged in large part to the capacity of these microorganisms to
develop resistance to antibiotics, and gatifloxacin is ideal for this
purpose. The presence of prednisolone in the product's formulation
complements the anti-bacterial action of gatifloxacin due to its
anti-inflammatory effects, and contributes to the efficacy of
gatifloxacin in the treatment and/or prevention of eye infections with a
critical inflammatory component.

[0012] The present invention is directed to a gatifloxacin and
prednisolone composition in the form of a sterile solution for ophthalmic
topical use. The use of a combination drug with an anti-infective
component is indicated where the risk of infection is high or where there
is an expectation that potentially dangerous numbers of bacteria will be
present in the eye. The anti-inflammatory component of the composition is
useful in treating inflammation associated with physical trauma to
ophthalmic tissues, inflammation associated with bacterial infections and
inflammation resulting from surgical procedures. The combination of
gatifloxacin and prednisolone is also useful in post-operative
inflammation where there is an increased chance of bacterial infection.
The compositions of the invention may also be used prophylactically in
connection with various ophthalmic surgical procedures that create a risk
of bacterial infection. Other examples of ophthalmic conditions which may
be treated with the compositions of the present invention include
infective conditions with associated inflammation and where the use of
steroid is acceptable; such conditions may include, but not limited to
conjunctivitis, keratitis, blepharitis, dacryocystitis, hordeolum and
corneal ulcers.

[0013] The composition of the present invention contains gatifloxacin in
ranges of 0.01% w/v-1.5% w/v, 0.05% w/v-1.0% w/v; 0.1% w/v-1.0% w/v; 0.1%
w/v-0.5% w/v but most preferable concentration of gatiflaxocin is 0.3%
w/v. The composition of the present invention also contains prednisolone
acetate in ranges between 1-20 mg/ml including 0.01% w/v-2.0% w/v, 0.05%
w/v-1.5% w/v, 0.1% w/v-1.5% w/v but most preferably USP 10 mg (1.0% w/v).
In combination, the most preferable concentration of gatifloxacin and
prednisolone is 0.3% w/v of gatifloxacin to 1.0% w/v of prednisolone.

[0014] The gatifloxacin/prednisolone composition of the present invention
is specially formulated for topical application to ophthalmic tissues.
The composition is sterile and has physical properties which are ideally
suited for application to ophthalmic tissues, including tissues that have
been compromised as the result of preexisting disease, trauma, surgery or
other physical conditions.

[0015] The antibiotic concentration of gatifloxacin of 0.01% w/v-1.5% w/v
and in particular 0.3% w/v in the present composition contains an ideal
amount of gatifloxacin sufficient to provide a concentration in the
aqueous humor and lacrimal fluid of the eye equal to or greater than the
MIC90 (minimum inhibitory concentration levels to inhibit 90% growth)
relative to gram-negative and gram-positive organisms commonly associated
with ophthalmic infections. This amount is referred to as "an
antimicrobial effective concentration". Gatifloxacin works by inhibiting
DNA gyrase and topoisomerase IV both of which are necessary for the
replication of bacteria.

[0016] The composition of the present invention also contains prednisolone
acetate in ranges between 1-20 mg/ml but most preferably USP 10 mg (1.0%
w/v) as an anti-inflammatory agent. The anti-inflammatory agent utilized
in the present invention is broadly classified as steroidal. Prednisolone
acetate is a glucocorticoid and has three to five times the
anti-inflammatory potency of hydrocortisone. Glucocorticoides inhibit
edema and fibrin disposition, phagocytic migration, capillary
proliferation and deposition of collagen and scar tissue. The
concentration of the anti-inflammatory agents contained in the
composition of the present invention is based on the type of inflammation
being treated. The concentration is sufficient to reduce inflammation in
the targeted ophthalmic tissues following topical application of the
compositions to those tissues. Such an amount is referred to as "an
anti-inflammatory effective amount".

[0017] One preferred embodiment of the present invention showing the
concentrations of active ingredients is the following:

[0019] The composition of the current invention is administered to the
affected ophthalmic tissues by topically applying one to four drops of
the sterile suspension one to four times per day/eye or more as
indicated.

[0020] Benzalkonium chloride is used as the preferred preservative in the
present invention. However, it is possible that other preservatives
commonly used in ophthalmic solutions be utilized such as Purite®
(chlorine dioxide), polixetonium, polyhexamethylene biguanide, polyquad
and sodium perborate.

[0033] 12) The composition of paragraph 11 wherein the benzalkonium
chloride is present in the amount of 0.005% w/v.

[0034] 13) The
composition of paragraphs 10-12 wherein the pH is in the range of 6.5 to
7.4.

[0035] 14) The composition of paragraph 1 and 10-13 wherein the
composition has an osmotic value from 250 to 350 milliosmoles per
kilogram of water.

[0036] 15) The composition of paragraphs 1 and 10-14
wherein the composition is provided as a kit containing a 1-10 ml plastic
dropper designed for topical administration of the composition.

[0037]
16) The composition of paragraphs and 10-14 wherein the composition is
provided as a kit containing a 5 ml plastic dropper designed for topical
administration of the composition.

[0038] 17) The composition of
paragraphs 1 and 10-14 wherein the composition may be used for treatment
of bacterial conjunctivitis by applying 1-4 drops of the composition to
each eye per day.

[0039] 18) The composition of paragraphs 1 and 10-14
wherein the composition may be used for prevention and treatment of
inflammatory conditions following eye surgery by applying 1-4 drops of
the composition to each eye per day.

[0040] 19) The composition of
paragraphs 1 and 10-14 wherein the composition may be used for prevention
and treatment of inflammatory conditions before or following eye surgery
by applying 1-4 drops of the composition to each eye per day.

[0041] 20)
The composition of paragraphs 1 and 10-14 wherein the composition may be
used for prevention of bacterial conjunctivitis following eye surgery by
applying 1-4 drops of the composition to each eye per day.

BRIEF DESCRIPTION OF THE DRAWINGS

[0042] FIGS. 1A-1B show a basic manufacturing process for the
gatifloxacin/prednisolone composition of the present invention.

DETAILED DESCRIPTION OF THE INVENTION

[0043] The bactericidal mechanism of action of fluoroquinolones, including
gatifloxacin, is different than those of the aminoglycosides, macrolides
and tetracycline antibiotics.

[0044] Therefore, gatifloxacin can be effective/active against pathogenic
agents resistant to these antibiotics and these antibiotics can be active
against pathogenic agents resistant to gatifloxacin. No cross-resistance
has been observed among gatifloxacin and previous mentioned classes of
antibiotics. Cross-resistance has been observed among systemic
gatifloxacin and some other fluoroquinolones.

[0045] Gatifloxacin (4th generation fluoroquinolone, approved in 2003
as a 0.3% solution called Zymar®, marketed by Allergan), shows a
broad spectrum of antibacterial activity against gram-positive and
gram-negative microorganisms, anaerobic organisms, mycobacteria and
species of Mycoplasma, and Chlamydia. Several studies have been conducted
comparing the antibacterial activity of gatifloxacin to the activity of
other classes of antibiotics and other fluoroquinolones. In vitro studies
showed that gatifloxacin is more powerful than other quinolones,
including ciprofloxacin, ofloxacin, levofloxacin and moxifloxacin against
gram-positive microorganisms such as methicillin resistant Staphylococcus
aureus, and Staphylococcus epidermidis. Gatifloxacin was eight times more
effective than ofloxacin against Streptococcus epidermidis and showed
increased activity compared to ofloxacin against many gram-negative
microorganisms. Gatifloxacin was two times more effective than ofloxacin
against Haemophilus influenzae clinical isolated cases. In other studies,
gatifloxacin was four times more effective/active than ciprofloxacin
against mycobacterium, was more effective than ciprofloxacin (p<0.001)
against Mycbacterium chelonae and showed a synergistic action when
combined with amikacin and claritromycin. Besides these studies, one
other study was conducted comparing the activity of gatifloxacin with
that of moxifloxacin, ciprofloxacin and ofloxacin in vitro. Investigators
concluded that the sensitivity profiles achieved by the 4th
generation fluoroquinolones (gatifloxacin and moxifloxacin) can offer
advantages over 2nd generation fluoroquinolones (ciprofloxacin and
ofloxacin). In vitro studies showed that the bacterial resistance to
gatifloxacin is low.

[0046] Bacterial resistance rates regarding resistant mutant strains of
Pseudomonas aeruginosa and Escherichia coli for gatifloxacin are similar
to ciprofloxacin and norfloxacin. However, bacterial resistance rates for
Staphylococcus aureus and Staphylococcus epidermidis are lower for
gatifloxacin than for ciprofloxacin or norfloxacin. Gatifloxacin was also
less affected by topoisomerase II or gyrase mutations, when compared to
ofloxacin, ciprofloxacin, sparfloxacin and trovafloxacin.

[0047] The ophthalmic composition of the present invention is contained in
pharmaceutically acceptable excipients and vehicles. The excipients used
in the manufacturing of the current invention are Methocel (F4M) HPMC IP
(Indian Pharmacopeia) as suspending agent; Disodium Hydrogen Phosphate as
buffer salt; Potassium Dihydrogen Phosphate BP as buffer salt; Disodium
Edetate IP as chelating agent; Hydrochloric Acid 0.5 N as solubilizer for
gatifloxacin; Sodium Hydroxide for pH adjustment; hydrochloric acid for
pH adjustment and purified water as a vehicle.

[0048] The composition of the present invention has a pH in the range of
6.5 to 7.4. The ophthalmic composition has been formulated to have
osmotic values that are compatible with the aqueous humor of the eye and
ophthalmic tissues. Such osmotic values will generally be in the range of
from about 250 to about 350 milliosmoles per kilogram of water
("mOsm/kg"). The formulation is designed to have particle size wherein
95% of particles are less than 7 micron and no particle more than 10
micron. The formulation also has a weight per ml in the range of 0.9 g/ml
and 1.1 g/ml.

[0049] Ophthalmic pharmaceutical product is packaged in a multidose form.
Preservatives are thus required to prevent microbial contamination during
use. Suitable preservatives include benzalkonium chloride and other
agents known to those skilled in the art. In the current formulation
benzalkonium chloride USP 0.05 mg (0.005% w/v) is used as an effective
preservative.

[0050] The present composition can be provided in a kit containing 1-10 ml
plastic dropper bottles designed for topical administration of ophthalmic
solution. A 5 ml plastic dropper is preferred.

Pharmacokinetic Data

[0051] In relation to gatifloxacin pharmacokinetics, a study was conducted
whereby gatifloxacin ophthalmic solution (0.3% or 0.5% w/v) was instilled
in one of the eyes of 6 healthy male individuals in a dose-escalation
regimen, beginning with a single dose of 2 drops, followed by 2 drops, 4
times a day, for 7 days; and finally, 2 drops, 8 times a day, for 3 days.
During the assessment period, the plasma levels of gatifloxacin remained
below the inferior limit of quantification (5 ng/ml) in all individuals
who participated in the study, showing that the concentrations of
gatifloxacin were acceptably low after application to the eye and that it
would have little to no effect on the systemic safety profile. On the
other hand, there have been studies comparing the penetration of
gatifloxacin in the eye structures, when compared the ciprofloxacin, has
been observed that the gatifloxacin has better penetration in the tissue
(p<0.005). Solomon R, Donnenfeld E D, Perry H D, Snyder R W, Nedrud C,
Stein J, Bloom A. "Penetration of topically applied gatifloxacin 0.3%,
moxifloxacin 0.5%, and ciprofloxacin 0.3% into the aqueous humor."
Ophthalmology, 2005; 112(3):466-469.

[0052] A study comparing the pharmacodynamic of gatifloxacin and
ciprofloxacin showed the impact of gatifloxacin pharmacokinetics in
relation to ciprofloxacin on the drugs' antimicrobial effects.
Gatifloxacin showed a longer half-life than ciprofloxacin and the results
of this study showed the important role of a longer half-life, resulting
in a superior antimicrobial effect. Vostrov S N, Kononenko O V, Lubenko I
Y, Zinner S H, Firsov A A. "Comparative pharmacodynamics of gatifloxacin
and ciprofloxacin in an in vitro dynamic model: prediction of
equiefficient doses and the breakpoints of the area under the curve/MIC
ratio." Antimicrob Agents Chemother 2000; 44(4):879-884.

Clinical Aspects

[0053] Gatifloxacin

[0054] Results of previous pre-clinical and clinical studies showed that
gatifloxacin in an ophthalmic solution is clinically safe and effective
in the treatment of infections caused by bacteria. The 0.3% gatifloxacin
at ophthalmic solution Zymar® was shown to be effective in the
treatment of acute bacterial conjunctivitis in children and adults,
including elderly people. In a randomized, double-blind, multicenter
clinical study, in which the patients were treated for five days,
Zymar® ophthalmic solution was superior to the vehicle between days 5
and 7 in the treatment of patients with bacterial conjunctivitis
confirmed by culture. The results of the clinical study showed a clinical
cure rate for 77% of the group treated with gatifloxacin compared to 58%
to the group treated with placebo. The microbiological results in this
study showed a statistically significant superiority of gatifloxacin, and
the killing rate of etiological agents for gatifloxacin was 92% versus
72% for placebo. In active-controlled comparative study, the rates of
microbiological cure on day 6 of treatment were similar for gatifloxacin
(83.3%) and ofloxacin (85.3%).

[0055] In one other randomized, double-blind study comparing gatifloxacin
to ciprofloxacin in patients with keratitis, the group treated with
gatifloxacin showed a significantly higher rate of complete ulcer healing
than the group treated with ciprofloxacin. The action of gatifloxacin
against gram-positive cocci was significantly superior to that of the
ciprofloxacin (p<0.001), and the percentage of ulcers caused by these
healed pathogens in the gatifloxacin group was significantly higher in
the group treated with gatifloxacin (p=0.009). The authors concluded that
the gatifloxacin can be a preferred alternative in relation to
ciprofloxacin in the treatment of bacterial keratitis.

[0056] The efficacy and safety of gatifloxacin 0.3% and levofloxacin 0.5%
ophthalmic solutions were compared in a prospective study in which
patients received treatment for one week, in the pre-operative period of
a cataract surgery and the results have shown that the rate of bacterial
reduction in the conjunctiva was 74.3% (55/74 individuals) for
gatifloxacin and 70.0% (42/60 individuals) for levofloxacin. None of the
individuals treated develop a post-operative infection (endophthalmitis),
which shows that both substances were effective in the reduction of
bacterial flora in the eye, and may be safely indicated for the
prophylactic treatment in the pre-operative period.

[0057] The most commonly isolated bacteria in clinical studies conducted
with Zymar® were Staphylococcus aureus, Staphylococcus epidermidis
and Streptococcus pneumoniae. However, the varieties of bacteria observed
during the studies include all species commonly reported as etiological
agents of conjunctivitis. In vitro tests of 379 isolated microorganisms
showed that there was 95.8% sensitiveness to gatifloxacin on the first
day of treatment. All Streptococcus pneumoniae isolates were sensitive to
gatifloxacin in all study visits both in relation to gatifloxacin and the
controls. All gram-negative bacteria were also sensitive to gatifloxacin
in all study visits both in relation to gatifloxacin and controls,
including all Haemophilus influenzae isolates.

[0058] The adverse events reported during the clinical studies conducted
with gatifloxacin were similar to those reported for other ophthalmic
preparations containing fluoroquinolones. There were no statistically
significant differences between gatifloxacin and the active control
ofloxacin or placebo in terms of frequency, type, intensity or relation
to the causes of adverse events. The ophthalmologic exams and the visual
acuity assessment were also similar among the patients treated with the
active substances and the placebo. The phase III clinical studies, which
evaluated the systemic exposition of gatifloxacin in an ophthalmic
solution 0.3% (Zymar®) did not detect the effects described for the
quinolone class including phototoxic or allergic reactions, as well as
cardiovascular, articular or tendinous/sinewy diseases. Adverse events in
the central nervous system were rare.

[0059] It has been concluded that the gatifloxacin ophthalmic solution
0.3% (Zymar®) for topical use shows an excellent safety profile with
low systemic exposure and without evidence of the effects of quinolone
class. Therefore, the properties described for gatifloxacin justify the
choice of its inclusion in the composition of the present invention in
combination with prednisolone for topic ocular use.

Prednisolone

[0060] Prednisolone acetate is 21-acetate of
11β,17,21-triidroxipregna-1,4 diene-3,20-dione substance that
suppress the inflammatory response in relation to a variety of agents
that slow the healing process. Prednisolone is a corticosteroid and as
such may prevent or suppress inflammation in response to multiple events,
including infectious, chemical, radioactive, mechanical and immunological
stimuli. Although the use of corticosteroids as anti-inflammatories is
not aimed to treat the primary cause of the disease, the suppression of
inflammation is extremely useful in clinical terms. Multiple mechanisms
are involved in the suppression of inflammation by glucocorticoids, and
it is understood today that glucocorticoids inhibit the production of
certain inflammatory factors by various cells which cause an inflammatory
response. As a result, use of prednisolone results in the reduction in
the release of vasoactive and chemical active factors, the reduction of
lipolytic and proteolytic enzyme secretion and the reduction of leukocyte
outflow to damaged areas and reduction of fibrosis. Thus, in relation to
the eye, the anti-inflammatory response comprises a series of inhibitory
phenomena on exudation, hyperemia, cell infiltration, fibroblastic
activity, epithelial and endothelial regeneration, neo-vascularization
and capillary permeability in the eye structures.

[0061] While prednisolone acetate ophthalmic suspension is contraindicated
in most viral diseases of the cornea and conjunctiva including epithelial
herpes simplex keratitis (dendritic keratitis), vaccinia, varicella,
mycobacterial infection of the eye and fungal diseases of ocular
structures, it has been surprisingly found that that when combined with
gatifloxacin at 0.3% w/v, the overall risk benefit of use of prednisolone
in combination in indicated conditions is highly favorable.

[0062] The combination of gatifloxacin and prednisolone in a single
composition in the concentrations stated herein is novel and has
characteristics which may be considered similar in concept to traditional
combination therapies, but demonstrates superior properties to other
combination ophthalmic products.

Clinical Data:

[0063] Post marketing data of the use of the combination was obtained by a
physician experience questionnaire. The objective of the physician
experience questionnaire was to evaluate the opinion of ophthalmologists'
for safety, efficacy and compliance of the combination. The second
objective was to have physician experience on the present formulation
versus existing similar combination or individual treatment. The data
collection is still ongoing. Data obtained from 102 physicians has been
compiled and is presented below. The composition referred to as Z-Pred is
the 0.3% w/v gatifloxacin and 1.0% w/v prednisolone combination with
benzalkonium as a preservative as described herein.

Methodology: The following questions were used to access physician's
opinion on the combination.

[0064] 1. Have you prescribed Z-Pred?
Answers were obtained as Yes/No.

[0065] 2. In your clinical experience
how would you rate the effectiveness of Z-Pred in the treatment of
steroid responsive inflammatory ocular conditions? The ratings were
obtained on a five point rating scale: very effective, effective, neither
effective nor ineffective, ineffective and not at all effective.

[0066]
3. Do you use Z-Pred in cases such as pre & post surgical where a
corticosteroid is indicated & where bacterial infection or a risk of
bacterial ocular infection exist? Answers were obtained as Yes/No.

[0067]
4. What has been your level of satisfaction in above cases (Q. No.3)? The
ratings were obtained on a five point rating scale: very satisfactory,
satisfactory, neither satisfactory nor dissatisfactory, dissatisfactory
and very dissatisfactory.

[0068] 5. In your clinical experience have you
seen any major adverse events seen with the use of Z-Pred? Answers were
obtained as Yes/No.

[0069] 6. Would you rate Z-Pred better than the
similar existing anti-infective & steroid fixed dose combinations?
Answers were obtained as Yes/No.

[0070] 7. Do you see a better patient
compliance with Z-Pred as compared to individual drug therapy? Answers
were obtained as Yes/No. Results: Result of the questionnaire from 102
physicians is presented in table below.

TABLE-US-00004

[0070] TABLE II
SI. N
No Parameters Assessment Criteria 102 (%)
1 Have you prescribed Z-Pred? Yes 101 99.0
No 1 1.0
2 In your clinical experience how would you rate the effectiveness of Very
effective/Effective 101 99.0
Z-Pred in the treatment of steroid responsive inflammatory ocular Neither
effective nor ineffective 1 1.0
conditions? Ineffective 0 0.0
Not at all eff 0 0.0
3 Do you use Z-Pred in cases such as pre & post surgical where a Yes 87
85.3
corticosteroid is indicated & where bacterial infection or a risk of No
14 13.7
bacterial ocular infection exist?
4 What has been your level of Satisfaction in above cases (Q. No. 3)? Very
satisfactory/Satisfactory 92 90.2
Neither satisfactory nor dissatisfactory 2 2.0
Dissatisfactory 0.0
Very dissatisfactory 0.0
5 In your clinical experience have you seen any major adverse events Yes 6
5.9
seen with the use of Z-Pred? No 96 94.1
6 Would you rate Z-Pred better than the similar existing anti-infective
Yes 92 90.2
& steroid fixed dose combinations? No 6 5.9
7 Do you see a better patient compliance with Z-Pred as compared to Yes
101 99.0
individual drug therapy? No 1 1.0

Results:

[0071] In the survey, it was observed that most physicians prescribed the
combination in their clinical practice (99%). As shown in Table I, most
physicians rated the combination as very effective or effective for (99%)
for treatment of steroid responsive ocular conditions. Similarly, 85.3%
physicians used the combination for pre- and post-surgical cases where a
corticosteroid was indicated and where bacterial infection or risk of
bacterial infection existed. The level of satisfaction with the
combination was generally high, with 90.2% physicians rating their level
of satisfaction as either very satisfactory or satisfactory (combined
percentage being 90.2%). There were 2% of total cases who answered as
neither satisfactory nor dissatisfactory. None rated the treatment as
dissatisfactory or very dissatisfactory.